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MULTIPLE PERSON DEMOGRAPHIC AND HEALTH SURVEY
EDS-MICS 2011
HOUSEHOLD QUESTIONNAIRE

REPUBLIC OF CAMEROON
PEACE WORK FATHERLAND
NATIONAL INSTITUTE OF STATISTICS

IDENTIFICATION:

LOCALITY NAME: ___
NAME OF HEAD OF HOUSEHOLD: ___
REGION: ___
CLUSTER NUMBER: ___
STRUCTURE NUMBER: ___
HOUSEHOLD NUMBER: ___

URBAN/RURAL:

URBAN 1
RURAL 2

RESIDENCE:

YAOUNDÉ 1
DOUALA 2
GAROUA/MAROUA/BAFOUSSAM/BAMENDA/NGAOUNDERE 3
OTHER CITIES 4
RURAL 5

HOUSEHOLD SELECTED FOR MEN'S SURVEY AND HIV TEST?

YES 1
NO 2

INTERVIEWER VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___

RESULTS___

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT MEMBER AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR A LONG PERIOD
4 DELAYED
5 REFUSED
6 DWELLING VACANT HOUSING OR NOT ELIGIBLE TO ADDRESS
7 HOUSE DESTROYED
8 HOUSING NOT FOUND
9 OTHER (SPECIFY): ___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__

TOTAL NUMBER OF VISITS____

QUESTIONNAIRE LANGUAGE:

FRENCH 1
ENGLISH 2

INTERVIEW LANGUAGE:

FRENCH 1
ENGLISH 2
FULFULDE 3
EWONDO 4
PIDGIN 5
OTHERS 6

INTERPRETER?

YES 1
NO 2

TOTAL IN HOUSEHOLD: ___
TOTAL NUMBER OF ELIGIBLE WOMEN: ___
TOTAL NUMBER OF ELIGIBLE MEN: ___
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE: ___

FIELD EDITED BY:

NAME: ___
DATE ___

SUPERVISOR:

NAME: ___
DATE ___

OFFICE EDITED BY:
NAME: ___

KEYED BY:
NAME: ___

INFORMED CONSENT

Hello. My name is ___and I am working with the National Institute of Statistics. We are conducting, in collaboration with the Ministry of Health, a national of various health problems. We would very much appreciate your participation in this survey. The survey usually takes between 20 and 25 minutes to complete.

In this study, we would first like to ask you some questions about your household. All information you provide will be kept strictly confidential and will not be shared with anyone outside of the investigation team. Participation in this survey is completely voluntary. If I happened to ask a question you do not want to answer, let me know and I'll move on to the next question, or you can stop the interview at any time. However, we hope that you will participate in this survey since your opinion is very important.

At this time, do you want to ask me anything about the survey?

May I begin the interview now?

INTERVIEWER SIGNATURE: ___
DATE: ___

RESPONDENT AGREES TO ANSWER: ___
RESPONDENT REFUSES TO ANSWER QUESTIONS: ___ (GO TO END)

HOUSEHOLD TABLE

Now we would like some information on the people usually living in your household or who currently live with you.

1) LINE NUMBER:

2) USUAL RESIDENTS AND VISITORS:
Please give the name of those persons usually living in your household or who spent last night here, starting with the head of household.

AFTER HAVING LISTED THE NAMES OF THE MEMBERS OF THE HOUSEHOLD AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK THE APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

3) AFFILIATION WITH THE HEAD OF HOUSEHOLD:
What is the familial relation between (NAME) and the head of household?

HEAD OF HOUSEHOLD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON OR DAUGHTER-IN-LAW 04
GRANDSON OR GRANDDAUGHTER 05
FATHER OR MOTHER 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
DIRECT NEPHEW, NIECE 09
NEPHEW OR NIECE THROUGH MARRIAGE 10
OTHER RELATIVE 11
ADOPTED/FOSTER/STEP CHILD 12
NO FAMILY RELATIONSHIP 13
DK 98

4) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

5) RESIDENCE: Does (NAME) normally live here?

YES 1
NO 2

6) RESIDENCE: Did (NAME) sleep here last night?

YES 1
NO 2

7) AGE: How old is (NAME)?

IN YEARS: ___

8) MARITAL STATUS: What is the marital status of (NAME)?

MARRIED OR LIVING TOGETHER 1
DIVORCED/SEPARATED 2
WIDOWER/WIDOW 3
HAS NEVER LIVED WITH SOMEONE 4

9) ELIGIBILITY: CIRCLE THE LINE NUMBER OF WOMEN BETWEEN AGES 15-49.

10) ELIGIBILITY: CHECK THE COVER PAGE. IF HOUSEHOLD SELECTED FOR THE MEN'S SURVEY, 1 (YES), CIRCLE THE LINE NUMBER OF MEN BETWEEN AGES 15-59 IF MEN'S SURVEY IS PLANNED.

11) CHECK THE COVER PAGE. IF HOUSEHOLD SELECTED FOR THE MEN'S SURVEY, 2 (NO), CIRCLE THE LINE NUMBER OF ALL CHILDREN BETWEEN 0-5 YEARS OLD.

2A. Just to be sure I have a complete listing, are there any other person such as small children or infants that we have not listed?

YES: ___ (ADD TO THE TABLE)
NO: ___

2B. Are there any other people who may not be members of your family, such as domestic servants, employees, tenants or friends who usually live here?

YES: ___ (ADD TO THE TABLE)
NO: ___

2C. Do you have guests or temporary visitors or others who slept here last night and were not listed?

YES: ___ (ADD TO THE TABLE)
NO: ___

13) PARENTAL SURVIVORSHIP: Is his or her mother still living?

YES 1
NO 2 (GO TO 16)
DK 8 (GO TO 16)

14) Does the biological mother live in this household or did she visit last night?

IF YES : What is her name ?

WRITE LINE NUMBER OF MOTHER.

IF NOT, WRITE '00'.

_____

16) Is his or her father still living?

YES 1
NO 2 (GO TO 23)
DK 8 (GO TO 23)

17) ALIVE : Does the biological father live in this household or did he visit last night?

IF YES : What is his name?

WRITE LINE NUMBER OF FATHER.

IF NOT, WRITE '00'.

_____

23) IF 3 YEARS OLD OR OLDER: Did (NAME) attend school? Or kindergarten?

YES 1
NO 2 (GO TO 23)

24) What is the highest level of education (NAME) completed ?
What is the last class that he or she successfully completed?

LEVEL:

PRIMARY 1
SECONDARY, 1ST CYCLE 2
SECONDARY, 2ND CYCLE 3
HIGHER 4

CLASS:

PRIMARY
LESS THAN ONE YEAR 0
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
DK 8
SECONDARY
LESS THAN ONE YEAR 0
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
DK 8
HIGHER
LESS THAN ONE YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH+ YEAR 4
DK 8

25) IF BETWEEN AGES OF 3 AND 24: CURRENT OR RECENT SCHOOL ATTENDANCE: Did (NAME) attend school or kindergarten at any time during the 2010-2011 school year?

YES 1
NO 2 (GO TO 27)

26) During this current school year, what level and class was (NAME) in?

LEVEL:

PRIMARY 1
SECONDARY, 1ST CYCLE 2
SECONDARY, 2ND CYCLE 3
HIGHER 4

CLASS:

PRIMARY
LESS THAN ONE YEAR 0
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
DK 8
SECONDARY
LESS THAN ONE YEAR 0
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
DK 8
HIGHER
LESS THAN ONE YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH+ YEAR 4
DK 8

27) Did (NAME) attend school or kindergarten at any time during the last school year (2009-2010)?

YES 1
NO 2 (GO TO 32)

28) During this school year, what level and class was (NAME) in ?

LEVEL:

PRIMARY 1
SECONDARY, 1ST CYCLE 2
SECONDARY, 2ND CYCLE 3
HIGHER 4

CLASS:

PRIMARY
LESS THAN ONE YEAR 0
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
DK 8
SECONDARY
LESS THAN ONE YEAR 0
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
DK 8
HIGHER
LESS THAN ONE YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH+ YEAR 4
DK 8

32) IF BETWEEN 0 AND 4 YEARS OLD: BIRTH DECLARATION: Does (NAME) have birth certificate?

IF NO, PROBE: Was (NAME)'s birth declared to the state?

HAS AN ACT/ CERTIFICATE 1
DECLARED 2
NEITHER 3
DK 8

***CODES FOR QUESTIONS 24, 26, AND 28: EDUCATION LEVEL

DECEASED PERSONS

33) Now I would like to ask you some more questions about your household. Think about the past 12 months. Did a member of your household die during the past 12 months?

YES 1
NO 2 (GO TO 101)
DK 8 (GO TO 101)

34) How many members of your household died during the past 12 months?

NUMBER OF DEATHS: ___

35) ASK 36-38 AS APPROPRIATE FOR EACH DECEASED PERSON. IF THERE ARE MORE THAN THREE DECEASED PEOPLE, USE ADDITIONAL FORM(S).

36) What are the names of the member(s) of your household died during the past 12 months?

NAME OF 1ST DECEASED PERSON: ___
NAME OF 2ND DECEASED PERSON: ___
NAME OF 3RD DECEASED PERSON: ___

37) Was (NAME) a man or a woman?

MALE 1
FEMALE 2

38) How old was (NAME) at the time of death?

RECORD AGE IN DAYS IF FEWER THAN 30 DAYS.

RECORD AGE IN COMPLETED YEARS IF 24 MONTHS (2 YEARS) OR MORE.

RECORD '95' IF 95 YEARS OR MORE.

DAYS: ___ 1
MONTHS: ___ 2
YEARS: ___ 3

HOUSEHOLD CHARACTERISTICS

101) Where does the water your household uses for drinking mainly come from?

PIPED WATER
PIPED INTO THE RESIDENCE 11 (GO TO 106)
PIPED INTO COURTYARD OR PLOT 12 (GO TO 106)
PUBLIC TAP 13 (GO TO 103)
PUMP WELL 21 (GO TO 103)
DUG WELL
COVERED WELL 31 (GO TO 103)
UNCOVERED WELL 32 (GO TO 103)
SPRING WATER
COVERED SPRING 41 (GO TO 103)
UNCOVERED SPRING 42 (GO TO 103)
RAIN WATER 51 (GO TO 106)
TANK TRUCK 61 (GO TO 103)
CART WITH SMALL TANK/ BARREL 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/IRRIGATION CANAL) 81 (GO TO 103)
BOTTLED/POUCH WATER 91
OTHER (SPECIFY): ___ 96 (GO TO 103)

102) Where does the water that the members of your household use for other things such as cooking or hand washing mainly come from?

PIPED WATER
PIPED INTO THE RESIDENCE 11 (GO TO 106)
PIPED INTO COURTYARD OR PLOT 12 (GO TO 106)
PUBLIC TAP 13
PUMP WELL 21
DUG WELL
COVERED WELL 31
UNCOVERED WELL 32
SPRING WATER
COVERED SPRING 41
UNCOVERED SPRING 42
RAIN WATER 51 (GO TO 106)
TANK TRUCK 61
CART WITH SMALL TANK/ BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/IRRIGATION CANAL) 81 BOTTLED/POUCH WATER 91
OTHER (SPECIFY): ___ 96

103) Where is this supply source located?

IN RESIDENCE 1 (GO TO 106)
IN PLOT/YARD 2 (106)
ELSEWHERE 3

104) How much time is needed to go there, get drinking water, and come back?

MINUTES: ___
DK 998

104A) How many kilometers away is this drinking water supply?

KILOMETERS: ___
DK 98

105) Who normally goes to the water supply to get drinking water?

RECORD '00' IF THIS PERSON IS NOT A MEMBER OF THE HOUSEHOLD.

NAME: ___
LINE NUMBER: ___

NAME: ___
LINE NUMBER: ___

NAME: ___
LINE NUMBER: ___

NAME: ___
LINE NUMBER: ___

105A) Among those cited, who most frequently goes to the water supply for drinking water?

NAME: ___
LINE NUMBER: ___

106) Do you do anything to make the water safer to drink?

YES 1
NO (GO TO 108)
DK (GO TO 108)

107) What do you usually do to make it safer?

Anything else?

RECORD ALL MENTIONED.

BOIL A
ADD BLEACH/CHLORINE B
FILTER THROUGH CLOTH C
USE A (CERAMIC/SAND/COMPOSITE/ETC) FILTER D
SOLAR DISINFECTION E
LET SIT F
OTHER (SPECIFY): ___ X
DK Z

108) What kind of toilet do the majority of the members of your household use?

FLUSH / MANUAL FLUSH / FLUSH CONNECTED TO:
SEWAGE SYSTEM 11
SEPTIC TANK 12
LATRINES 13
SOMETHING ELSE 14
DON'T KNOW WHERE 15
PIT/LATRINE
IMPROVED SELF-VENTILATING LATRINE 21
LATRINE WITH SLAB 22
LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOST TOILET 31
BUCKET/TOILET PAIL 41
SUSPENDED TOILET/LATRINE 51
NO TOILET/NATURE 61 (GO TO 111)

109) Do you share this installation with other households?

YES 1
NO 2 (GO TO 111)

110) How many households, in all (including yours) use these toilets?

NUMBER OF HOUSEHOLDS IF FEWER THAN 10: ___
10 OR MORE HOUSEHOLD S 95
DK 98

111) In your household do you have:

Electricity?
A radio?
A television?
A mobile telephone?
A landline telephone?
A refrigerator?
A stove?
Gas heating?
Air conditioning?
A fan?
A CD/DVD player?
A computer?
A grain mill?
A mixer?
An internet connection?
Cable or satellite television?
An electricity generator?
A water pump?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
LANDLINE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
STOVE
YES 1
NO 2
GAS HEATING
YES 1
NO 2
AIR CONDITIONING
YES 1
NO 2
FAN
YES 1
NO 2
CD/DVD PLAYER
YES 1
NO 2
COMPUTER
YES 1
NO 2
GRAIN MILL
YES 1
NO 2
MIXER
YES 1
NO 2
INTERNET
YES 1
NO 2
CABLE CONNECTION
YES 1
NO 2
GENERATOR
YES 1
NO 2
WATER PUMP
YES 1
NO 2

112) What kind of fuel does your household mainly use for cooking?

ELECTRICITY 01 (GO TO 115)
LPG (GO TO 115)
NATURAL GAS 03 (GO TO 115)
BIOGAS 04 (GO TO 115)
KEROSENE/PETROL 05
COAL/LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/ GRASS 09
AGRICULTURAL CROP 10
DUNG 11
NO MEALS PREPARED IN HOUSEHOLD 95 (GO TO 117)
OTHER (SPECIFY): ___ 96

113) In this household, do you cook on an open flame, open oven, or closed oven?

OPEN FLAME 1
OPEN OVEN 2
CLOSED OVEN WITH CHIMNEY 3 (GO TO 115)
OTHER (SPECIFY): ___ 6 (GO TO 115)

114) Does the fire/oven have a chimney, hood, or neither?

CHIMNEY 1
HOOD 2
NEITHER 3

115)Is the cooking normally done in the house, in a separate building, or outside?

IN THE HOUSE 1
IN SEPARATE BUILDING 2 (GO TO 117)
OUTSIDE 3 (GO TO 117)
OTHER (SPECIFY): ___ 6 (GO TO 117)

116) Do you have a separate area you use for cooking?

YES 1
NO 2

117) PRINCIPLE FLOORING MATERIAL.

(WRITE DOWN OBSERVATION)

NATURAL MATERIAL
EARTH/ SAND 11
DUNG 12
RUDIMENTARY MATERIAL
WOOD PLANKS 21
PALM LEAVES/ BAMBOO 22
MODERN MATERIAL
PARQUET OR POLISHED WOOD 31
VINYL OR LINOLEUM/ASPHALT 32
TILE OR STONE SLABS 33
CEMENT 34
CARPET 35
OTHER (SPECIFY): ___ 96

118) MAIN MATERIAL OF ROOF.

(WRITE DOWN OBSERVATION)

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
SOD 13
RUDIMENTARY MATERIAL
RUSTIC MAT 21
PALM LEAVES/ BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED FLOOR
METAL 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
SHINGLES 35
CEMENT 34
CARPET 35
OTHER (SPECIFY): ___ 96

119) MAIN MATERIAL OF EXTERIOR WALLS

RECORD OBSERVATION

NATURAL WALLS
NO WALLS 11
BAMBOO/CANE/PALM/TRUNKS/LEAVES/BARK 12
EARTH 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED MATERIALS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY): ___ 96

120) How many rooms in this household do you use for sleeping?

NUMBER OF ROOMS: ___

121) Does any member of this household own:

A watch/clock?
A bicycle?
A motorcycle or scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?

WATCH/CLOCK
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
BOAT WITH A MOTOR
YES 1
NO 2

122) Does anyone in your household own any agricultural land?

YES 1
NO 2 (GO TO 124)

123) How many hectares of agricultural land do members of this household own?

IF LESS THAN A HECTARE, RECORD '00'.

HECTARES: ___
95 HECTARES OR MORE 95
DK 98

124) Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO (GO TO 126)

125) How many of the following does this household own?

IF NONE, ENTER '00'.

IF 95 OR MORE, ENTER '95'.

IF UNKNOWN ENTER '98'.

Cattle?
Cows/Bulls?
Horses/donkeys/mules?
Goats?
Sheep?
Pigs?
Fowl?

CATTLE: ___
COWS/BULLS: ___
HORSES/DONKEYS/MULES: ___
GOATS: ___
SHEEP: ___
PIGS: ___
FOWL: ___

126) Does any member of this household have a bank account?

YES 1
NO 2

127) Are you or anyone else the proprietor of this dwelling or are you a renter?

PROPRIETOR
RENTER (GO TO 130)
FREE RENT/ ILLEGAL OCCUPANT/OTHER (GO TO 130)

128) Do you or anyone else in this household have a property title for this dwelling?

YES 1 (GO TO 132)
NO 2

129) What kind of written document do you have for the ownership of this dwelling?

PROPERTY TAX A (GO TO 132)
ELECTRICITY /WATER/TELEPHONE BILL B (GO TO 132)
CERTIFICATE OF SALE C (GO TO 132)
OTHER (SPECIFY): ___ X (GO TO 132)
NONE/NO DOCUMENT Y (GO TO 132)

130) Do you have written documentation for the rental of this dwelling?

YES 1
NO 2 (GO TO 132)
DK 8 (GO TO 132)

131) What kind of written document do you have for the rental of this dwelling?

IF YES: What type of document or agreement do you have for the rental of this dwelling?

INFORMAL AGREEMENT (WRITTEN) A
ORAL AGREEMENT (NO DOCUMENT) B
FREE OCCUPANCY WITH AGREEMENT T OF OWNER C
FREE OCCUPANCY WITHOUT AGREEMENT OF OWNER D
OTHER X
NOTHING/ NO DOCUMENT Y

132) Do you feel sure of not being kicked out of this dwelling?

YES 1
NO 2
DK 8

133) Have you been kicked out of your house at any time in the last five years?

YES 1
NO 2
DK 8

134) DWELLING SITUATED IN OR CLOSE TO:

OBSERVE AND CIRCLE ALL CODES THAT DESCRIBE THE LIVING SPACE.

LANDSLIDE ZONE A
FLOODPLAIN B
RIVERSIDE C
STEEP HILL D
LANDFILL E
INDUSTRIAL POLLUTION ZONE F
RAILROAD TRACK G
ELECTRICAL ENERGY GENERATION CENTER H
AIRFIELD I
NONE OF THE ABOVE Y

135) CONDITION OF THE DWELLING.

OBSERVE AND CIRCLE ALL CODES THAT DESCRIBE THE LIVING SPACE.

HOLES/OPENINGS IN WALLS A
NO WINDOWS B
BROKEN/NO WINDOWPANES C
VISIBLE HOLES IN ROOF D
PARTIAL ROOF E
DOOR UNSECURE F
NONE OF THE ABOVE Y

136) ENVIRONMENT OF DWELLING.

OBSERVE AND CIRCLE ALL CODES THAT DESCRIBE THE LIVING SPACE.

TOO NARROW PASSAGE BETWEEN DWELLINGS/ NO PATH A
TOO MANY ELECTRICAL CABLES CONNECTING NEIGHBORHOOD AND POWER SOURCE B
HIGH/MEDIUM TENSION CABLES NEAR DWELLING C
NONE OF THE ABOVE Y

137) ASK RESPONDENT FOR A SPOONFUL OF SALT TEST THE SALT TO CHECK THE PRESENCE OF IODINE.

RECORD THE PARTS PER MILLION

0 PPM (NO IODINE) 1
LESS THAN 15PPM 2
15 PPM OR MORE 3
NO SALT IN HOUSE 4
SALT NOT TESTED (SPECIFY REASON): ___ 5

CHECK COVER PAGE:

HOUSEHOLD NOT SELECTED FOR MEN'S SURVEY AND HIV TEST (NO = 2): ___
HOUSEHOLD SELECTED FOR MEN'S SURVEY AND HIV TEST (YES = 1): ___
(GO TO QUESTION 601 [HANDICAP])

MOSQUITO PROTECTION

201) Do the windows in the dwelling's living spaces have screens or curtains to prevent mosquitos from entering?

YES 1
NO 2

202) ) Do the doors in the dwelling's living spaces have screens or curtains to prevent mosquitos from entering?

YES 1
NO 2

203) In the last twelve months, did someone come here to spray the interior walls to protect from mosquitos?

YES 1
NO 2 (GO TO 207)
DK (GO TO 207)

204) How long ago did this spraying occur?

MONTHS SINCE SPRAYING: ___
DK 98

205) Who sprayed the dwelling?

GOVERNMENT PROGRAM 1
PRIVATE COMPANY 2
MEMBER OF HOUSEHOLD 3
OTHER (SPECIFY): ___ 6
DK 8

206) From the time the walls of your dwelling were sprayed, did you retouch them, for example, by putting mortar or paint on them, or put plaster on them or wash them?

YES 1
NO 2
DK/DON'T REMEMBER 8

207) Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 137)

208) How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF MOSQUITO NETS: ___

209) Do you use the mosquito nets outside the bedrooms, for example in the yard, under the trees?

YES 1
NO 2

210) Does your family sleep under mosquito nets year-round?

YES 1 (GO TO 213)
NO 2
DK/DON'T REMEMBER 8

211) Why don't your family members sleep under a mosquito net year-round?

NOT A LOT OF MOSQUITOS 1 (GO TO 213)
BECAUSE OF HEAT 2 (GO TO 213)
DON'T LIKE IT 3 (GO TO 213)
FORGETFULNESS 4 (GO TO 213)
OTHER (SPECIFY) 5 (GO TO 213)
DK/DON'T REMEMBER 8 (GO TO 213)

212) Why are there no mosquito nets that can be used in your household?

CIRCLE ALL CODES MENTIONED.

LACK MEANS A (GO TO 301)
NOT NECESSARY B (GO TO 301)
USES SOMETHING ELSE C (GO TO 301)
NOT A LOT OF MOSQUITOS D (GO TO 301)
DON'T LIKE E (GO TO 301)
OTHER (SPECIFY): ___ X (GO TO 301)
DK Y (GO TO 301)

213) ASK RESPONDENT TO SHOW YOU THE HOUSEHOLD'S MOSQUITO NETS.

IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

MOSQUITO NET # 1
SEEN 1
NOT SEEN 2
MOSQUITO NET # 2
SEEN 1
NOT SEEN 2
MOSQUITO NET # 3
SEEN 1
NOT SEEN 2

214) How many months has your household had this mosquito net?

IF LESS THAN A MONTH, RECORD '00'.

IF 3 YEARS OR MORE (36 MONTHS OR +) CIRCLE '95'.

MONTHS AGO: ___
MORE THAN 36 MONTHS AGO 95
DK 98

215) How did you obtain this mosquito net?

PURCHASED 1
MINISTRY OF HEALTH GIFT 2
NGO GIFT 3
FAMILY/FRIEND GIFT 4
OTHER (SPECIFY): ___ 6
DK 8

216) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

PERMANENT NET
OLYSET 11 (GO TO 220)
PERMANET 12 (GO TO 220)
OTHER/DK BRAND 16 (GO TO 220)
PRETREATED NET
DURANET 21 (GO TO 218)
INTERCEPTOR 22 (GO TO 218)
NET PROTECT 23 (GO TO 218)
OTHER/DK BRAND 26 (GO TO 218)
OTHER 96
DK BRAND 98

217) When you got this mosquito net, was it already treated with an insecticide to kill or repel mosquitos?

YES 1
NO 2
DK 8

218) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitos?

YES 1
NO 2 (GO TO 134)
DK 8 (GO TO 134)

219) How many months ago was the net last soaked or dipped?

IF LESS THAN ONE MONTH AGO, RECORD '00'.

MONTHS AGO: ___
24 OR MORE MONTHS 95
DK 98

220) Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 222)
DK 8 (GO TO 222)

221) Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___

222) RETURN TO QUESTION 213 FOR THE FOLLOWING MOSQUITO NET OR, IF NO MORE NETS, GO TO 301.

CHILDREN 'S WORK (FOR CHILDREN 5-12 YEARS OLD)

(ONLY IN HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY AND HIV TEST)

301) CHECK COLUMNS (5) AND (7): NUMBER OF CHILDREN BETWEEN 5 AND 14 USUALLY LIVING IN THE HOUSEHOLD:

ONE OR MORE:___
FILL IN THE TABLE FOR EACH CHILD BETWEEN 5 AND 14 YEARS OLD.
NONE: ___ (GO TO 401)

ASK THE FOLLOWING QUESTIONS OF THE PERSON RESPONSIBLE FOR EACH CHILD (IF MORE THAN 8 CHILDREN, USE ADDITIONAL QUESTIONNAIRE[S])

Now I would like to ask you some questions about the kind of work that children living her do.

302) RECORD THE LINE NUMBER OF EACH CHILD IN THE ORDER OF COLUMN 1 OF HOUSEHOLD SURVEY.

____

303) RECORD THE NAME OF EACH CHILD.

____

304) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), has (NAME) done any kind of work for someone not a member of this household?

IF 'YES': Was he/she paid in cash or kind for this work?

YES, PAID 1
YES, NOT PAID 2
NO 3 (GO TO 306)

305) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), about how many hours has (NAME) done any kind of work for someone not a member of this household?

____

306) In the last 12 months, has (NAME) done any kind of work for someone not a member of this household?

IF 'YES': Was he/she paid in cash or kind for this work?

YES, PAID 1
YES, NOT PAID 2
NO 3 (GO TO 309)

307) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), has (NAME) done any kind of work for a member of this household?

For example, done dishes, gone shopping, cleaned, laundered clothes, gotten water, or watched children?

YES 1
NO (GO TO 309)

308) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), about how many hours has (NAME) done housework?

___

309) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), has (NAME) done any other work for the family in the fields or in family business (farm, business, or street vending)?

YES 1
NO 2 (GO TO NEXT LINE)

310) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), about how many hours has (NAME) done any work for the family in the fields or in family business?

____

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5 YEARS

401) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF EACH CHILD BETWEEN 0-5 YEARS. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S) THE FINAL WEIGHT AND HEIGHT MEASUREMENT MUST BE RECORDED IN 409.

402) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NUMBER: ___
NAME: ___

403) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK THE DAY.

IF MOTHER NOT INTERVIEWED, ASK:
What is (NAME)'s date of birth?

DAY: ___
MONTH: ___
YEAR: ___

405) CHECK 403:
CHILD BORN IN JANUARY 2005 OR LATER OR UNDER 60 MONTHS?

YES 1
NO 2 (GO TO 403 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 501)

406) WEIGHT IN KILOGRAMS:

KG: ___

407) HEIGHT IN CENTIMETERS:

CM: ___

408) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

409) RESULT HEIGHT AND WEIGHT MEASURES

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

410) CHECK 403:
IS CHILD AGE 0-5 MONTHS , I.E.. WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO 403, NEXT CHILD. IF NO OTHER CHILDREN GO TO 501)
6 MONTHS OR MORE 2

411) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD
(COLUMN 1), RECORD '00' IF NOT LISTED.

LINE NUMBER: ___

412) READ CONSENT STATEMENT FOR ANEMIA TEST TO THE PARENT/ ADULT RESPONSIBLE FOR THE CHILD. CIRCLE THE APPROPRIATE CODE AND SIGN.

GRANTED 1
NOT GRANTED 2
SIGNATURE: ___

413) READ CONSENT STATEMENT FOR MALARIA TO THE PARENT/ ADULT RESPONSIBLE FOR THE CHILD. CIRCLE THE APPROPRIATE CODE AND SIGN.

GRANTED 1
NOT GRANTED 2
SIGNATURE: ___

414) CHECK 412-413 AND PREPARE THE NECESSARY INSTRUMENTS FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED. THEN , PERFORM THE TESTS. FOR EACH ELIGIBLE CHILD, THE RESULT OF THE ANEMIA TEST MUST BE RECORDED IN 415 AND IN 417 FOR MALARIA, EVEN IF CONSENT WAS NOT GIVEN, CHILD WAS NOT PRESENT, OR COULD NOT BE TESTED FOR OTHER REASONS.

415) RESULT CODE FOR ANEMIA TEST

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

416) NOTE HEMOGLOBIN LEVEL HERE IN THE ANEMIA PAMPHLET

G/DL

417) RESULT CODE FOR MALARIA TEST

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

418) RESULT OF MALARIA TEST

POSITIVE FOR FALCIPARUM PARASITE 1
POSITIVE FOR OTHER PARASITES 2
MIXED POSITIVE 3
NEGATIVE 4 (GO TO 403 FOR NEXT CHILD, OR, IF NO MORE CHILDREN, GO TO 501)
OTHER 6 (GO TO 403 FOR NEXT CHILD, OR, IF NO MORE CHILDREN, GO TO 501)

419) READ THE INFORMATION FOR MALARIA TREATMENT AND THE CONSENT STATEMENT TO THE PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD. CIRCLE THE APPROPRIATE CODE AND SIGN.

GRANTED 1
NOT GRANTED 2
SIGNATURE: ___

420) RETURN TO 403 IN THE NEXT COLUMN OR THE FIRST COLUMN OF NEXT QUESTIONNAIRE. IF NO OTHER CHILD, GO TO 501.
CONSENT DECLARATION FOR CHILD ANEMIA TEST.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2005 or later take part in anemia testing in this survey and give a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

CONSENT DECLARATION FOR CHILD MALARIA TEST

As part of this survey, we are asking people all over the country to take a malaria test. Malaria is a serious health problem caused by a parasite transmitted by mosquito bites. This survey will assist the government to develop programs to prevent and treat malaria.

We ask that all children born in 2005 or later take part in anemia testing in this survey and give a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the malaria test?

TREATMENT FOR CHILDREN WITH A POSITIVE MALARIAL PARASITE TEST

IF THE MALARIAL PARASITE TEST IS POSITIVE:

The diagnostic test for malaria shows that your child has malaria.

We can give free medication. These medications are called ANTIMALARIAL COMBINATION THERAPY (ACT). ACT is very effective and will in a few days eliminate the fever and other symptoms. ACT is also very safe. However, as with every medication, there are side effects, and this medication can have them.

The most common side effects are vertigo, fatigue, loss of appetite, and palpitations. The combination treatment should never be taken by persons with a serious heart condition or a serious case of malaria (for example Cerebral) or problems regulating salt levels in the body

ASK IF CHILD SUFFERS FROM ONE OF THESE PROBLEMS, TO THE MOTHER'S KNOWLEDGE IF SO, THE ACT MUST NOT BE GIVEN. EXPLAIN THE RISKS OF MALARIA, AND REFER THE CHILD TO THE NEAREST HEALTH FACILITY.

You do not have to give the child the medication. It is for you to decide. Please tell me if you accept the medication or not.

ACT TREATMENT (Artesumate and Amodiquine)
Approximate weight (KG)
Fewer than 9 kgs (less than a year)
Between 9- 18kgs (1-5 years)

DOSAGE
DAY 1 (once a day) 1 pill (Artesunate 25mg + Amodiaquine 67.5 mg)
DAY 1 (once a day) 1 pill (Artesunate 50mg + Amodiaquine 135 mg)

DAY 2 (once a day) 1 pill (Artesunate 25mg + Amodiaquine 67.5 mg)
DAY 2 (once a day) 1 pill (Artesunate 50mg + Amodiaquine 135 mg)

DAY 3 (once a day) 1 pill (Artesunate 25mg + Amodiaquine 67.5 mg)
DAY 3 (once a day) 1 pill (Artesunate 50mg + Amodiaquine 135 mg)

MUST ALSO BE SAID TO MOTHER/ ADULT RESPONSIBLE FOR THE CHILD:

If (NAME OF CHILD) has one of the following symptoms, you must take him or her immediately to a health professional to receive care:

- High fever
- Convulsions, coma
- Rapid breathing or difficulty breathing
- Unable to drink or nurse
- Becomes sicker or does not improve after 2 days

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR WOMEN AGE 15-49 YEARS

501) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF EACH WOMAN BETWEEN 15 AND 49 YEARS OLD.

IF MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

THE FINAL WEIGHT AND HEIGHT MEASUREMENT MUST BE RECORDED IN 505 AND IN 512 FOR THE RESULT OF THE ANEMIA TEST.

502) LINE NUMBER FROM COLUMN 9.
NAME FROM COLUMN 2.

LINE NUMBER: ___
NAME: ___

503) WEIGHT IN KILOGRAMS.

KG: ___

504) HEIGHT IN CENTIMETERS.

CM: ___

505) RESULT HEIGHT AND WEIGHT MEASURES.

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

505A) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 508)

506) MARITAL STATUS: CHECK COLUMN 8.

CODE 4 (NEVER IN A UNION) 1
OTHER 2 (GO TO 508)

507) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENTS.

RECORD '00' IF PERSON NOT LISTED.

LINE NUMBER: ___

508) READ CONSENT STATEMENT FOR ANEMIA TEST. FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

GRANTED 1 (SIGN)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)
RESPONDENT REFUSED 3 (SIGN) (GO TO 512)
SIGNATURE: ___

CONSENT DECLARATION FOR ANEMIA TEST

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 508 IF RESPONDENT ACCEPTS THE ANEMIA TEST AND CODE '3' IF SHE REFUSES.

FOR WOMEN BETWEEN 15 AND 17 NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 507 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENTS HERSELF. CIRCLE CODE '2' IN 508 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For this survey, we need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to participate in the anemia test?
Do you agree to participate in the anemia test?

LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

LINE NUMBER: ___
NAME: ___

509) CHECK QUESTION 226 FROM WOMEN'S QUESTIONNAIRE.

Are you pregnant?

YES 1
NO 2
DK 8

510) CHECK 508 AND PREPARE THE NECESSARY INSTRUMENTS FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED. THEN, PERFORM THE TESTS. FOR EACH ELIGIBLE WOMAN, THE RESULT OF THE ANEMIA TEST MUST BE RECORDED IN 512. EVEN IF CONSENT WAS NOT GIVEN, RESPONDENT WAS NOT PRESENT, OR COULD NOT BE TESTED FOR OTHER REASONS.

511) NOTE HEMOGLOBIN HERE AND ON THE BROCHURE ON ANEMIA.

G/DL: ___

512) RESULT CODE FOR ANEMIA TEST.

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

513) RETURN TO QUESTION 503 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 514.

514) WOMEN'S SELECTION TABLE FOR "HOUSEHOLD RELATIONS" (ONLY FOR THE HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

THE SECTION ON "HOUSEHOLD RELATIONS" IN THE WOMEN'S INDIVIDUAL QUESTIONNAIRE APPLIES TO WOMEN IN HOUSEHOLDS FOR WHICH THERE IS NEITHER A MEN'S SURVEY NOR AN HIV TEST.
HOWEVER, ONLY A SINGLE WOMAN PER HOUSEHOLD WILL BE SURVEYED IN THIS SECTION. THE BELOW TABLE ALLOWS YOU TO SELECT THIS WOMAN AT RANDOM.

1 - THERE IS ONLY ONE ELIGIBLE WOMAN IN THE HOUSEHOLD
This woman will be selected for the "HOUSEHOLD RELATIONS" section of the women's questionnaire

2 - THERE ARE MORE THAN ONE ELIGIBLE WOMEN IN THE HOUSEHOLD

a) take the last digit of the structure number recorded on the questionnaire cover page
b) this is the line number digit to be selected
c) check the total number of eligible women in column 9 in the Household Table.
d) this number is that of the column to be selected.
e) find the box that corresponds to the intersection of the line of the intersecting columns and circle this number.
f) this number corresponds to the woman who will be selected for the "HOUSEHOLD RELATIONS" section: the 1st, 2nd,3rd, etc.
g) In column 9 of the household table, circle the line number of the woman.

Example:
The household structure number is 136: select line 6.
There are 3 eligible women in the household, select column 3.
The box at the intersection of line 6 and column 3 is 2: the 2nd eligible woman listed in the household table will be selected.
If the line number of these 3 eligible women is : '02', '04' and '07', the woman selected is the second woman listed, so, that of the line number '04'.

Last digit of structure number:
0
1
2
3
4
5
6
7
8
9

Total number of eligible women:
1 2 3 4 5 6 7 8 9 10+
1 2 2 3 5 5 3 6 8 9
1 1 3 4 1 6 4 1 6 4 7 9 10
1 2 1 1 2 1 5 8 1 1
1 1 2 2 3 2 6 1 2 2
1 2 3 3 4 3 7 2 3 3
1 1 1 4 5 4 1 3 4 4
1 2 2 1 1 5 2 4 5 5
1 1 3 2 2 6 3 5 6 6
1 2 1 3 3 1 4 6 7 7
1 1 2 4 4 2 4 5 7 8 8

NAME OF WOMAN SELECTED: ___

LINE NUMBER OF THE WOMAN SELECTED IN THE HOUSEHOLD TABLE: ___

THIS HOUSEHOLD NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST (END)

HANDICAP (ONLY FOR HOUSEHOLDS SELECTED FOR MEN'S SURVEY AND HIV TEST)

601) Now I would like to ask some questions about the health of each person usually living in your household, including small children.

Is there anyone in your household who is missing a limb, for example, a hand, an arm, a foot, or a leg?

IF YES: Can you give me the names of these people?

YES 1
NO 2 (GO TO 604)

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING A LIMB. ASK 603 ABOUT THE 1ST PERSON, THEN THE 2ND PERSON, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

602) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___

603) Has (NAME) had this problem since birth, or is it due to an accident, an illness, or another cause?

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

604) Is there anyone in your household with a deformity of an upper or lower extremity and who cannot walk or has difficulty walking and/or using his/her arms or hands?

IF YES: Could you tell me the names of these people?

YES 1
NO 2 (GO TO 608)

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH A DEFORMITY. ASK 606 AND 607 FOR THE 1ST PERSON, THEN THE 2ND PERSON, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

605) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___

606) Has (NAME) had this deformity from birth or was it caused by an accident, and illness, or another cause?

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

607) Does (NAME) only have difficulty using his/her arms or legs, or can (NAME) not use his/her arms or legs at all?

PARTIAL HANDICAP 1
TOTAL HANDICAP 2

608) Is anyone in your household blind or nearly blind?

IF YES: Can you tell me the name of these people?

YES 1
NO 2 (GO TO 612)

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH VISION PROBLEMS. ASK 610 AND 611 OF THE 1ST PERSON, THEN THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

609) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___

610) Has (NAME) had vision problems since birth, or were the problems caused by an accident, an illness, or another cause?

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

611) Does (NAME) have trouble seeing or is (NAME) completely blind?

PARTIAL VISION LOSS 1
BLIND 2

612) Is there anyone in your household who is almost or completely deaf?

IF YES: Can you tell me the names of these people?

YES 1
NO 2 (GO TO 616)

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH HEARING PROBLEMS. ASK 614 AND 615 OF THE 1ST PERSON, THEN THE 2ND PERSON, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

613) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___

614) Did (NAME) have hearing problems since birth or were they caused by an accident, an illness, or another cause?

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

615) Does (NAME) have difficulty hearing or is (NAME) completely deaf?

PARTIAL HEARING LOSS 1
DEAF 2

616) Is there anyone in your household that has serious difficulty talking or is mute?

IF YES: Can you tell me the names of these people?

YES 1
NO 2 (GO TO 620)

RECORD THE NAME AND NUMBER OF EACH PERSON WITH SPEECH PROBLEMS. ASK 618 AND 619 FOR THE FIRST PERSON, THEN THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

617) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___

618) Has (NAME) had these problems with talking since birth or were they caused by an accident, an illness, or another cause?

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

619) Does (NAME) have difficulty speaking or is (NAME) completely mute?

PARTIAL SPEAKING LOSS 1
MUTE 2

620) Is there anyone in your household who is missing certain bodily extremities, such as finger tips, toes, nose, or ears?

IF YES: Can you tell me the names of these people?

YES 1
NO 2 (GO TO 624)

RECORD NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING CERTAIN BODY PARTS. ASK 622 AND 623 FOR THE 1ST PERSON, THEN THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

621) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___

622) Has (NAME) had this problem since birth or was it caused by an accident, an illness, or another cause?

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

623) Does name have certain extremities that have no feeling?

YES 1
NO 2
DON'T KNOW 8

624) Does anyone in your household have behavioral problems?

IF YES: Can you tell me the names of these people?

YES 1
NO 2 (GO TO 701)

RECORD NAME AND LINE NUMBER OF EACH PERSON WITH BEHAVIORAL PROBLEMS. ASK 626 AND 627 FOR THE 1ST PERSON, THEN THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

625) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___

626) Has (NAME) had this problem since birth or was it caused by an accident, and illness, or another cause?

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

627) Are (NAME)'s problems mild or serious?

MILD 1
SERIOUS 2
DON'T KNOW 8

HOUSEHOLD HEALTH EXPENSES (ONLY FOR HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

701) Is a member of your household currently ill, or suffering from a long term illness or injury, or was ill in the last 30 days?

YES 1
NO 2 (GO TO 801)

702) How many members of your household are currently sick, or suffering from a long term illness or injury, or were ill in the last 30 days?

NUMBER OF SICK PEOPLE: ___

703) Now I'd like to ask you some questions about each person who was ill or injured at one point or another in the last 30 days. Can you tell me each person's name?
Then we will talk in detail about each one, one after another.

RECORD IN 704 THE NAME AND LINE NUMBER OF EACH SICK PERSON, THEN ASK ALL THE RELEVANT QUESTIONS FOR EACH PERSON. FINISH ASKING ALL THE QUESTIONS ABOUT THE FIRST SICK PERSON BEFORE MOVING ON TO THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 SICK PEOPLE, USE THE ADDITIONAL QUESTIONNAIRE.)

704) NAME AND LINE NUMBER COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE

SICK PERSON 1
NAME: ___
LINE NUMBER: ___
SICK PERSON 2
NAME: ___
LINE NUMBER: ___
SICK PERSON 3
NAME: ___
LINE NUMBER: ___

705) In your opinion, was (NAME)'s illness serious, moderate, or mild?

SERIOUS 1
MODERATE 2
MILD 3
DON'T KNOW 8

706) Did they use self-treatment?

YES 1
NO 2 (GO TO 710)

707) From whom did they seek drugs for the self-treatment?

PHARMACY 1
DRUG VENDOR (TRAVELLING, MARKET) 2
PLANT COLLECTION 3
DRUGS ALREADY AVAILABLE AT HOME 4 (GO TO 709)
OTHER (SPECIFY): ___ 6

708) What was the total sum of the drug purchases for (NAME)'s self-treatment?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

709) After the self-treatment, did you seek advice or other care to treat (NAME)'s illness or injury?

YES 1 (GO TO 711)
NO 2 (GO TO 726)

710) Did you seek advice or other care to treat (NAME)'s illness or injury?

YES 1
NO 2 (GO TO 726)

711) From whom did they seek advice or treatment for (NAME)'s illness/injury?

IF "HOSPITAL" OR "HEALTH CENTER", CHECK THE NAME AND TYPE AND CIRCLE THE APPROPRIATE CODE.

IF "DOCTOR" OR "NURSE", CHECK TO SEE IF THE SICK PERSON WENT TO THE INDIVIDUAL OR IF THE "DOCTOR"/ "NURSE" WENT TO THE SICK PERSON'S DWELLING. CIRCLE THE APPROPRIATE CODE.

PUBLIC SECTOR
REFERRAL HOSPITAL 11
REGIONAL HOSPITAL 12
DISTRICT HOSPITAL 13
LOCAL MEDICAL CENTER 14
CS/INTEGRATED HEALTH CENTER/PMI 15
OTHER PUBLIC 16
PRIVATE SECTOR
CLINIC/OFFICE 21
DWELLING OF HEALTH CARE PROFESSIONAL 22
HEALTH PROFESSIONAL'S VISIT TO SICK PERSON'S HOME 23
OTHER PRIVATE 24
NON-MEDICAL SECTOR
PHARMACY 31
DRUG VENDOR (TRAVELLING, MARKET) 32
TRADITIONAL PRACTITIONER 33
RELIGIOUS HEALER 34
OTHER (SPECIFY): ___ 96

712) What was the total sum of the expenses for transportation to go to and return from (LOCATION OF CARE IN 711)?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

713) What was the total sum of the expenses for the consultation and care at (LOCATION OF CARE IN 711)?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

714) What was the total sum of expenses for drugs, exams, and other products prescribed at (LOCATION OF CARE IN 711)?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

715) Was (NAME) admitted to the hospital for at least one night to treat his/her illness/injury?

YES 1
NO 2 (GO TO 718)

716) What was the total sum of expenses for this hospitalization?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

717) What was the total sum of expenses for transportation to this hospitalization?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

718) After the first visit to (LOCATION OF CARE FROM 711), was there a second consultation at the same place or were there other visits to seek care to treat (NAME)'s illness/injury elsewhere?

YES 1
NO 2 (GO TO 726)

719) For this second visit, from whom did you seek advice or treatment to treat (NAME)'s illness/injury?

PUBLIC SECTOR
REFERRAL HOSPITAL 11
REGIONAL HOSPITAL 12
DISTRICT HOSPITAL 13
LOCAL MEDICAL CENTER 14
CS/INTEGRATED HEALTH CENTER/PMI 15
OTHER PUBLIC 16
PRIVATE SECTOR
CLINIC/OFFICE 21
DWELLING OF HEALTH CARE PROFESSIONAL 22
HEALTH PROFESSIONAL'S VISIT TO SICK PERSON'S HOME 23
OTHER PRIVATE 24
NON-MEDICAL SECTOR
PHARMACY 31
DRUG VENDOR (TRAVELLING, MARKET) 32
TRADITIONAL PRACTITIONER 33
RELIGIOUS HEALER 34
OTHER (SPECIFY): ___ 96

720) What was the total sum of the expenses for transportation to go to and return from (LOCATION OF CARE IN 711)?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

721) What was the total sum of expenses for the consultation and care from (LOCATION OF CARE FROM 719)?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

722) What was the total sum of expenses for the drugs, exams, and other products prescribed at (LOCATION OF CARE FROM 719)?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

723) Was (NAME) admitted to the hospital for at least one night to treat his/her illness/injury?

YES 1
NO 2 (GO TO 726)

724) What was the total sum of expenses for this hospitalization?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

725) What was the total sum of expenses for transportation to this hospitalization?

AMOUNT IN FCFA.

FCFA: ___
FREE 000000
PAID IN KIND 999995
DON'T KNOW 999998

726) Check 708, 712, 713, 714, 716, 717, 720, 721, 722, 724 and 725:

MONETARY EXPENSES (IN FCFA): ___
NO MONETARY EXPENSES: ___ (GO TO 729)

727) Who paid the expenses for the care and treatment of (NAME)'s illness/injury?

RECORD THE NAME AND LINE NUMBER OF THE PERSON(S) WHO PAID.
ENTER '00' IF THE PERSON DOES NOT LIVE IN THE HOUSEHOLD.

NAME (1): ___
LINE NUMBER: ___
DON'T KNOW 98
NAME (2): ___
LINE NUMBER: ___
NAME (3): ___
LINE NUMBER: ___

728) Where did (NAME (1) FROM 727) get the money to pay for the expenses incurred for the care and treatment of (NAME)'s illness/injury?

SALARY/AVAILABLE MONEY A
SAVINGS B
LOAN WITH NO INTEREST C
LOAN WITH INTEREST D
SALE OF GOODS OR ASSETS E
OTHER SOURCES X
DON'T KNOW Z

Where did (NAME (2) FROM 727) get the money to pay for the expenses incurred for the care and treatment of (NAME)'s illness/injury?

SALARY/AVAILABLE MONEY A
SAVINGS B
LOAN WITH NO INTEREST C
LOAN WITH INTEREST D
SALE OF GOODS OR ASSETS E
OTHER SOURCES X
DON'T KNOW Z

Where did (NAME (3) FROM 727) get the money to pay for the expenses incurred for the care and treatment of (NAME)'s illness/injury?

SALARY/AVAILABLE MONEY A
SAVINGS B
LOAN WITH NO INTEREST C
LOAN WITH INTEREST D
SALE OF GOODS OR ASSETS E
OTHER SOURCES X
DON'T KNOW Z

729) GO BACK TO 705 IN NEXT COLUMN; OR, IF NO MORE SICK PEOPLE, GO TO 801.

HIV TEST FOR WOMEN BETWEEN 15 AND 49 YEARS OLD (ONLY IN HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

801) CHECK COLUMN 9 IN HOUSEHOLD TABLE. RECORD THE LINE NUMBER AND THE NAME OF ALL WOMEN BETWEEN 15 AND 49 IN QUESTION 802.
IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE(S)
THE FINAL RESULT OF THE BLOOD TEST FOR HIV MUST BE RECORDED IN 809

802) LINE NUMBER FROM COLUMN 9.
NAME FROM COLUMN 2.

LINE NUMBER: ___
NAME: ___

803) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 806)

804) MARITAL STATUS: CHECK COLUMN 8.

CODE 4 (NEVER IN A UNION) 1
OTHER 2 (GO TO 806)

805) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENTS.

RECORD '00' IF PERSON NOT LISTED.

LINE NUMBER: ___

806) READ CONSENT STATEMENT FOR HIV TEST. FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

GRANTED 1 (SIGN)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)
RESPONDENT REFUSED 3 (SIGN, AND GO TO 809)
SIGNATURE: ___

807) CHECK 806 AND PREPARE THE NECESSARY INSTRUMENTS AND DRAW THE BLOOD. FOR EACH ELIGIBLE WOMAN, THE CODE FOR THE RESULT MUST BE RECORDED IN 809, EVEN IF CONSENT WAS NOT GIVEN, RESPONDENT WAS NOT PRESENT, OR COULD NOT BE TESTED FOR OTHER REASONS.

808) BAR CODE LABEL.

PUT THE FIRST BAR CODE HERE

PUT THE SECOND BAR CODE ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.

809) RESULT OF THE HIV TEST.

BLOOD DRAWN 1
ABSENT 2
REFUSED 3
OTHER 4

CONSENT DECLARATION FOR HIV TEST

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 806 IF RESPONDENT ACCEPTS THE HIV TEST AND CODE '3' IF SHE REFUSES.
FOR WOMEN BETWEEN 15 AND 17NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 806 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

As part of this survey, we are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious health problem. This test will assist the government to measure the severity of the problem of AIDS in Cameroun.

For this test, we need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

No name will be attached to the blood samples and we will not be able to tell you the results. No one else will be able to know (NAME OF ADOLESCENT) results either. If you would like to know if you have HIV, I can give you a list of the (closest) facilities that offer tests and counseling for HIV. I would also give you a coupon for free services in these facilities for you (and for your partner if you would like).

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to participate in the HIV test?
Do you agree to participate in the HIV test?

LINE NUMBER FROM COLUMN 9.
NAME FROM COLUMN 2.

LINE NUMBER: ___
NAME: ___

810) CHECK 809: PARTICIPATION IN HIV TEST.

BLOOD SAMPLE TAKEN: ___
BLOOD SAMPLE NOT TAKEN: ___ (GO TO NEXT WOMAN)

811) READ CONSENT STATEMENT FOR ADDITIONAL TESTS. FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

GRANTED 1 (SIGN)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)
RESPONDENT REFUSED 3 (SIGN)
SIGNATURE: ___

812) ADDITIONAL TESTS:

CHECK 811:
IF CONSENT NOT GIVEN, WRITE: 'NO OTHER TESTS' ON THE FILTER PAPER.

813) RETURN TO 803 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR THE FIRST COLUMN OF NEW QUESTIONNAIRE. IF NO OTHER WOMEN, GO TO 814.

CONSENT DECLARATION FOR ADDITIONAL TESTS

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 811 IF RESPONDENT ACCEPTS THE TESTS AND CODE '3' IF SHE REFUSES.
FOR WOMEN BETWEEN 15 AND 17NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 811 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

We ask you to authorize the Pasteur Center of Cameroon to retain a part of the blood sample in the laboratory to be used in future tests or research. We do not know exactly what tests will be performed.

No name or other identifying information will be attached to the blood samples. You are not obligated to accept.

If you do not want the blood sample to be retained, you can still participate in this survey's HIV test (you can still authorize [NAME OF ADOLESCENT] to participate in this survey's HIV test).

Do you agree to allow us to retain the blood sample for future tests or research?

HIV TEST FOR MEN BETWEEN 15 AND 49 YEARS OLD (ONLY IN HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

814) CHECK COLUMN 10 IN HOUSEHOLD TABLE. RECORD THE LINE NUMBER AND THE NAME OF ALL MEN BETWEEN 15 AND 49 IN QUESTION 815.
IF THERE ARE MORE THAN 3 MEN, USE ADDITIONAL QUESTIONNAIRE(S)
THE FINAL RESULT OF THE BLOOD TEST FOR HIV MUST BE RECORDED IN 822

815) LINE NUMBER COLUMN 10.
NAME COLUMN 2.

LINE NUMBER: ___
NAME: ___

816) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 819)

817) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN A UNION) 1
OTHER 2 (GO TO 819)

818) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT.

RECORD '00' IF PERSON NOT LISTED.

LINE NUMBER OF PARENT/RESPONSIBLE ADULT: ___

819) READ CONSENT STATEMENT FOR HIV TESTS FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT LISTED IN 818 BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

GRANTED 1 (SIGN)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)
RESPONDENT REFUSED 3 (SIGN, GO TO 822)
SIGNATURE: ___

820) CHECK 806 AND PREPARE THE NECESSARY INSTRUMENTS AND DRAW THE BLOOD. FOR EACH ELIGIBLE MAN, THE CODE FOR THE RESULT MUST BE RECORDED IN 809, EVEN IF CONSENT WAS NOT GIVEN, RESPONDENT WAS NOT PRESENT, OR COULD NOT BE TESTED FOR OTHER REASONS.

821) BAR CODE LABEL.

PUT THE FIRST BAR CODE HERE.

PUT THE SECOND BAR CODE ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.

822) RESULT OF THE HIV TEST.

BLOOD DRAWN 1
ABSENT 2
REFUSED 3
OTHER 4

CONSENT DECLARATION FOR HIV TEST

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 819 IF RESPONDENT ACCEPTS THE HIV TEST AND CODE '3' IF HE REFUSES.
FOR MEN BETWEEN 15 AND 17 NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 818 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 819 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

As part of this survey, we are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious health problem. This test will assist the government to measure the severity of the problem of AIDS in Cameroun.

For this test, we need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

No name will be attached to the blood samples and we will not be able to tell you the results. No one else will be able to know (NAME OF ADOLESCENT) results either. If you would like to know if you have HIV, I can give you a list of the (closest) facilities that offer tests and counseling for HIV. I would also give you a coupon for free services in these facilities for you (and for your partner if you would like).

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to participate in the HIV test?

Do you agree to participate in the HIV test?

LINE NUMBER FROM COLUMN 10.
NAME FROM COLUMN 2.

LINE NUMBER: ___
NAME: ___

823) CHECK 822: PARTICIPATION IN HIV TEST.

BLOOD SAMPLE TAKEN: ___
BLOOD SAMPLE NOT TAKEN: ___ (GO TO NEST MAN)

824) READ CONSENT STATEMENT FOR ADDITIONAL TESTS. FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

GRANTED 1 (SIGN)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)
RESPONDENT REFUSED 3 (SIGN)
SIGNATURE: ___

825) ADDITIONAL TESTS:

CHECK 824:
IF CONSENT NOT GIVEN, WRITE: 'NO OTHER TESTS' ON THE FILTER PAPER.

826) RETURN TO 816 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR THE FIRST COLUMN OF NEW QUESTIONNAIRE. IF NO OTHER WOMEN, GO TO 901.

CONSENT DECLARATION FOR ADDITIONAL TESTS

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 811 IF RESPONDENT ACCEPTS THE TESTS AND CODE '3' IF HE REFUSES.
FOR MEN BETWEEN 15 AND 17 NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 818 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 824 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

We ask you to authorize the Pasteur Center of Cameroon to retain a part of the blood sample in the laboratory to be used in future tests or research. We do not know exactly what tests will be performed.

No name or other identifying information will be attached to the blood samples. You are not obligated to accept.

If you do not want the blood sample to be retained, you can still participate in this survey's HIV test (you can still authorize [NAME OF ADOLESCENT] to participate in this survey's HIV test).

Do you agree to allow us to retain the blood sample for future tests or research?

901) MEN'S SELECTION TABLE FOR "HOUSEHOLD RELATIONS" (ONLY FOR THE HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

THE SECTION ON "HOUSEHOLD RELATIONS" IN THE MEN'S INDIVIDUAL QUESTIONNAIRE APPLIES TO WOMEN IN HOUSEHOLDS FOR WHICH THERE IS NEITHER A MEN'S SURVEY NOR AN HIV TEST.

HOWEVER, ONLY A SINGLE MAN PER HOUSEHOLD WILL BE SURVEYED IN THIS SECTION. THE BELOW TABLE ALLOWS YOU TO SELECT THIS MAN AT RANDOM.

1- THERE IS ONLY ONE ELIGIBLE MAN IN THE HOUSEHOLD
THIS MAN WILL BE SELECTED FOR THE "HOUSEHOLD RELATIONS" SECTION OF THE MEN'S QUESTIONNAIRE

2- THERE ARE MORE THAN ONE ELIGIBLE MEN IN THE HOUSEHOLD

A) TAKE THE LAST DIGIT OF THE STRUCTURE NUMBER RECORDED ON THE QUESTIONNAIRE COVER PAGE

B) THIS DIGIT IS THE ROW NUMBER TO BE SELECTED

C) CHECK THE TOTAL NUMBER OF ELIGIBLE MEN IN COLUMN 9 IN THE HOUSEHOLD TABLE.

D) THIS NUMBER IS THAT OF THE COLUMN TO BE SELECTED.

E) FIND THE BOX THAT CORRESPONDS TO THE INTERSECTION OF THE LINE OF THE INTERSECTING COLUMNS AND CIRCLE THIS NUMBER.

F) THIS NUMBER CORRESPONDS TO THE WOMAN WHO WILL BE SELECTED FOR THE "HOUSEHOLD RELATIONS" SECTION: THE 1ST, 2ND, 3RD, ETC.

G) IN COLUMN 10 OF THE HOUSEHOLD TABLE, CIRCLE THE LINE NUMBER OF THE MAN.

EXAMPLE:
THE HOUSEHOLD STRUCTURE NUMBER IS 136: SELECT LINE 6.
THERE ARE 3 ELIGIBLE MEN IN THE HOUSEHOLD, SELECT COLUMN 3.
THE BOX AT THE INTERSECTION OF LINE 6 AND COLUMN 3 IS 2: THE 2ND ELIGIBLE MAN LISTED IN THE HOUSEHOLD TABLE WILL BE SELECTED.
IF THE LINE NUMBER OF THESE 3 ELIGIBLE WOMEN IS : '02', '04' AND '07', THE MAN SELECTED IS THE SECOND WOMAN LISTED, SO, THAT OF THE LINE NUMBER '04'.

LAST DIGIT OF STRUCTURE NUMBER: ____
TOTAL NUMBER OF ELIGIBLE MEN: ____
NAME OF MAN SELECTED: ___
LINE NUMBER OF THE MAN SELECTED IN THE HOUSEHOLD TABLE: ___

THIS HOUSEHOLD NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST (END)